Test, treatment or procedure that is neither specifically covered nor excluded in Medicare law or guidelines.

Carriers make a coverage determination based upon the general acceptance of the test, treatment or procedure by the professional medical community as an effective and proven treatment for the condition for which it is being used.

No payment will be made under Medicare Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.

Billing beneficiaries for unreasonable services is prohibited!

5Medical Necessity

Medically necessary services

consistent with symptoms or diagnosis of illness or injury being treated

within generally accepted professional medical standards

not performed primarily for convenience of patient, attending physician, or supplier

furnished at a level that is safe and effective for patient

6Medical Necessity

Provider responsible for ensuring medical necessity of services

Documentation in the medical record must contain

information necessary to monitor the patients condition

support the level of service rendered

7Limited Coverage

Limited Coverage - the service is covered by Medicare only under certain circumstances

If the patients diagnosis is a non-covered diagnosis for that service, the claim will be denied!

Limited Coverage services require Advance Beneficiary Notice (ABN) or Waiver of Liability to bill the patient for the service.

8Local Coverage Determination (LCD)

Adapted from/developed with Medicare Part A Part B (carrier) LCD

Based on input from

Carrier Advisory Committee (CAC)

Intermediary Advisory Committee (IAC)

Physician medical community

Specialty providers

LCD developed in cooperation w/ IAC CAC

National Policy takes precedence over local policy!

9LCD / Limited Coverage

Providers/physicians are not held liable or required to make refund if

They did not know, and could not reasonably have been expected to know, that Medicare would not pay for the service.

Prior to furnishing the service, they properly notified the beneficiary that Medicare would not pay for the service, and after being so informed, the beneficiary agreed to pay for the service.

10Advance Beneficiary Notice (ABN)

Advance written notice to the beneficiary that the physician, provider or supplier believes that the service/item would likely be denied as not medically necessary

Created to protect beneficiaries from liability in denial cases when services were found not to be medically necessary

11Advance Beneficiary Notice (ABN)

Appropriately executed waiver / ABN

Proof that beneficiary had knowledge prior to furnishing the service/item that it would likely be denied as not medically necessary

Proof that patient agreed to be financially responsible for service/item

No ABN / Waiver of Liability

Provider/supplier could be held liable for charge if it is determined that he/she knew, or should have known, that the service/item would be denied as not medically necessary

PowerShow.com is a leading presentation/slideshow sharing website. Whether your application is business, how-to, education, medicine, school, church, sales, marketing, online training or just for fun, PowerShow.com is a great resource. And, best of all, most of its cool features are free and easy to use.

You can use PowerShow.com to find and download example online PowerPoint ppt presentations on just about any topic you can imagine so you can learn how to improve your own slides and
presentations for free. Or use it to find and download high-quality how-to PowerPoint ppt presentations with illustrated or animated slides that will teach you how to do something new, also for free. Or use it to upload your own PowerPoint slides so you can share them with your teachers, class, students, bosses, employees, customers, potential investors or the world. Or use it to create really cool photo slideshows - with 2D and 3D transitions, animation, and your choice of music - that you can share with your Facebook friends or Google+ circles. That's all free as well!

For a small fee you can get the industry's best online privacy or publicly promote your presentations and slide shows with top rankings. But aside from that it's free. We'll even convert your presentations and slide shows into the universal Flash format with all their original multimedia glory, including animation, 2D and 3D transition effects, embedded music or other audio, or even video embedded in slides. All for free. Most of the presentations and slideshows on PowerShow.com are free to view, many are even free to download. (You can choose whether to allow people to download your original PowerPoint presentations and photo slideshows for a fee or free or not at all.) Check out PowerShow.com today - for FREE. There is truly something for everyone!

presentations for free. Or use it to find and download high-quality how-to PowerPoint ppt presentations with illustrated or animated slides that will teach you how to do something new, also for free. Or use it to upload your own PowerPoint slides so you can share them with your teachers, class, students, bosses, employees, customers, potential investors or the world. Or use it to create really cool photo slideshows - with 2D and 3D transitions, animation, and your choice of music - that you can share with your Facebook friends or Google+ circles. That's all free as well!

For a small fee you can get the industry's best online privacy or publicly promote your presentations and slide shows with top rankings. But aside from that it's free. We'll even convert your presentations and slide shows into the universal Flash format with all their original multimedia glory, including animation, 2D and 3D transition effects, embedded music or other audio, or even video embedded in slides. All for free. Most of the presentations and slideshows on PowerShow.com are free to view, many are even free to download. (You can choose whether to allow people to download your original PowerPoint presentations and photo slideshows for a fee or free or not at all.) Check out PowerShow.com today - for FREE. There is truly something for everyone!